Provider Demographics
NPI:1891792271
Name:MIYAMOTO, MIKA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIKA
Middle Name:
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3364
Mailing Address - Country:US
Mailing Address - Phone:503-977-3275
Mailing Address - Fax:503-546-3014
Practice Address - Street 1:500 NW 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3364
Practice Address - Country:US
Practice Address - Phone:503-977-3275
Practice Address - Fax:503-546-3014
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR76251223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist